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Sunday, September 25, 2011

Behavioral Zen

I’m having lunch with one of my married sons and his wife, and they tell me that they visited my mother. “You should see her zipping down the halls in that new walker! Wow! It’s scary!” cries Cham.


“Is that thing even safe?” asks my son. He picked up his grandmother’s worry gene.

Well, we hope so.

“She sure seems to love it,” his wife adds.

Yes and no. It is snazzy, and it is red, and she does love it, to a degree. The silver one they sent with her from the hospital last year has two gliders instead of a back set of wheels (the red one is a 4-wheeler) and the gliders slow her down.

The physical therapist calls the silver one the very best, however, because there are so many ways to arrange the wheels, the height.  You can even exchange the gliders for wheels. One visit with a physical therapist or an occupational therapist, and your whole way of looking at things changes. These people are geniuses.

THE STORY

FD and I took Mom to a wedding tonight. Dear friends of ours married off a daughter to a wonderful young man, and seeing people we haven't seen in many, many years, makes me delirious. My mother had a great time, we all did, and I took her up to her apartment in her independent living facility afterward.

On the way up she tells me the many different things she had worried about before the wedding, and how none of her fears materialized.  (Crazy, I know.)  "They seemed so happy to see me!"

Well, yeah. 

As she settled into her nighttime rituals, I noticed she didn’t use either of her walkers. Not the trusty silver one with the gliders, not the new red one with four wheels.

“This is an accident waiting to happen,” I spit out. “They told you that you have to use your walker ALL of the time.”

“I don't want to become dependent,” she tells me. End of the matter.

Dependency is bad.

“It’s not like taking drugs. It’s good to have one or two of these things to depend upon.”

She gives me that look, as in, Well, some of us disagree.

“Would you rather be dependent upon a caregiver? Because all it takes is one good fall and this independence thing is over, a thing of the past.  Maybe for good.”

She looks sad. I don’t want to turn a wonderful, warm, intimate evening with friends into a sad night. Bubble bursting is not our thing. But I can't help myself and continue.

“Think of it this way. Has your doctor told you , 'S.  You should really try not to use that walker. Use it for emergencies, or when you go out, maybe, but it is better to avoid using it all the time because you might become dependent upon it.'
Has any health care professional ever told you this?”

She shakes her head.

Nu?” I ask. (Nu, rhymes with Jew, Yiddish for So, already? or maybe What do you say to that?)

We're on a roll here.

“They all say, as a matter of fact, Keep it close to you. You need it. At your age, you need it. Everyone expects you to have one. No one expects you to still be here, pooh, pooh, pooh, at your age, and not have a set of wheels.”

She looks at me incredulously, for only six months ago she surrendered the car keys.  The rant goes on.

“Think of it as a part of you. Think of yourself and the walker as one. It is an extension of you, the walker. You and the walker, one person.  My walker, myself.”

No expression. Blank.  No idea if she’s copping to this. I turn from her to set up her medicines for the week, she gets on pajamas. When I finish she is standing behind me. She’s holding onto the silver one.

therapydoc

Sunday, September 18, 2011

Out of the Darkness: Suicide Prevention

One more and I'll leave you alone for awhile.  I promise.  (blee neder*)

April Jervis shares this email with me.  I thought I should pass it along:
(italics mine)

This week the Center for Disease Control and Prevention just released 2008 data for leading causes of death for the nation (http://www.cdc.gov/injury/wisqars/leading_causes_death.html).

For 2008 there were 36,035 suicides and a suicide rate of 11.8.
Suicide ranked 10th as a cause of death, while for many years previous it had ranked 11th.

Looking at age groups it is the 3rd leading cause of death for ages 10 to 24, the 2nd leading cause for ages 25-34, and the 4th leading cause for ages 35-54. These are shocking and upsetting numbers.

(In the eighties, the elderly had top billing. We thought, Well, they're in pain, they suffer with so much physical disability. But these numbers indicate mental illness, depression specifically, is on the rise.)

You can help stop this sad trend. If you haven’t already made plans to, please join us next week for the
Out of the Darkness Chicagoland Community Walk. 
As you know, this event raises funds and awareness for the American Foundation for Suicide Prevention (AFSP). There is no registration fee or minimum fundraising requirement to participate. Registration and information can be found at http://afsp.donordrive.com/event/chicagoland

Please tell a friend, family members, neighbors, colleagues, & everyone else you know about this important event.


Thank you in advance for your support and participation.


Sincerely,

April R. Jervis, MBA, Illinois Area Director

You're welcome, April.

therapydoc

Out of the Darkness Chicagoland Community Walk

Saturday, September 24th Check in at 8 am | Walk at 9 am
Busse Woods Forest Preserve, Level 4, Elk Grove Village, IL

Please Register Online Now at

There is No Minimum Fundraising Requirement and No Registration Fee to Participate in this Event!

Walk Program:

+ Walk To Save Lives!
+ Walk to Raise Awareness!
+ Help reduce the stigma of depression, bipolar disorder, other mood disorders, and suicide.
+ Walk to Honor a Loved One!
+ Walk to Support the American Foundation for Suicide Prevention!

Help Us Spread The Word:
Email This Invitation to Your Friends & Family and Post Our Fliers!

Thank You for Your Support & Participation!
blee neder* Hebrew, rhymes with Gee, get her, means, no promises.

Saturday, September 17, 2011

A First Rate Revision

As soon as I published that last one I thought, "They'll take me to the mat."
( ENT, A First Rate Madness). But no one did.

You should have.

This is in reference to the parting shot,
That’s what I tell those young people . . . the ones who can’t do their homework; the ones who can’t make their brains go where everyone else's brains, those ordinary brains, have no problem going. Think, greatness. . .
A lie. My advice always has been, and will continue to be in step with the ordinary, the homoclites of my profession. Given an opening, we

encourage kids to meet their personal, their unique potential. Of course.
encourage them to strive to excel, to find their talent and work it. You bet.
encourage them to dream of fame, fortune and greatness. No dream, no reality.

But when we advise those under the influence of a touch of genetic excess, when they're high and they don't even know it, it's more like,
Think greatness, qualified
What we tell the hyperthymics, the hypomanics, those who suffer manic episodes, young and old, age is immaterial, what we say is nothing short of
Think greatness, aspire to greatness, but. . .
Listen to others when they are telling you to slow down.

Pay attention when more than one person is giving you the same message, especially a message you don't want to hear.

Worry when you and your plan, your genius, are the only thing you have been thinking about for several hours, to the exclusion of everyone else, everything else. Come back to the rest of us for awhile, bounce ideas around.

Think greatness, but love the ordinary, and never think, They don't matter.  What they think, what they say, does matter.  

Never say to yourself, I'm right The rest of them are crazy.  Could be, but what are the odds?  Seriously, what are the odds they are all crazy?

Question yourself when you have a lone opinion.  Think, Is what I'm pushing for really good for everyone? And even if it is, if they all disagree with you, is there anything to be gained in losing them in the power struggle?  (Relationship therapists frown upon cut-offs, assume the more friends, the better. Those who give in, who don't need to be right, who let others be right, have more friends.)

Think greatness but take criticism, welcome it, encourage feedback. We're all works in progress, and we all want to be special. But more important, making others feel worthy, valuing their thoughts and opinions, is a goes around, comes around thing. Valuing others is what makes people great.

The geniuses in my first paragraph of that post on September 16, are only happy if they have friends.

I tell them: If you follow those rules, if you take it on the chin when others tell you to chill, to listen, to pay more attention to them than to your insistent thoughts, then . . .

should you become President of the United States, or CEO; should you have it in you to become the next Martin Luther King or Mahatma Gandhi; then Yes! You will have the option of running the show, working your program, casting that deciding vote, taking the risks that will change the course of history (and if not you, then who?) And when that happens, others will say,
I voted for her!

I voted for him! 

I worked for her!

I knew him.

What a great person, too. Truly, a great person.

therapydoc

Thursday, September 15, 2011

A First Rate Madness

Sometimes in this business you are called upon to treat a madman, or a madwoman, someone seemingly psychotic, talking way over your head, out there, but still oriented times three (person, place, time).   You sense genius. You feel that this person is smarter than you are, or at least as smart.

You recognize, right away, undeniable talent and intellect. He is a song-writer, a one-hit wonder. She is an artist. He is a poet; she directs a television show. He is a computer programmer; she is a doctor. And you’re humble. You go home and think, why in the world see me?

But you know why.  The patient needs your particular genius, because his madness is getting in the way. Others are complaining, complaining so loudly, you can hear them and they're not in the room, not even in the building.  You suspect mental illness.

And it usually is.  Nassir Ghaemi, author of A First Rate Madness:  Uncovering the links between leadership and mental illness, is of the opinion that it isn't always so bad.  Indeed, some creative people have a hyperthymic temperament.  They rarely need therapy, not unless no one else will listen to them.  It is not a disorder.

A Wikipedia definition: 

Hyperthymic temperament or hyperthymia (from the Ancient Greek θυμός for "spiritedness") is characterized by a personality style or set of personality traits that include
  • increased energy and productivity
  • short sleep patterns
  • vividness, activity extroversion
  • self-assurance, self-confidence
  • strong will
  • extreme talkativeness
  • tendency to repeat oneself
  • risk-taking/sensation seeking
  • breaking social norms
  • very strong libido
  • love of attention
  • low threshold for boredom
  • generosity and tendency to overspend
  • emotion sensitivity
  • cheerfulness and joviality
  • unusual warmth
  • expansiveness
  • tirelessness
  • irrepressible, infectious quality
Put a nickle in and a hyperthymic personality will talk your head off.  Some of us prefer to call it hypomania, a step away from true mania, which keeps some people up all night for days at a time. We wonder how it lasts, that functional happiness, but it does for the blessed few. For most of us, what goes up, must come down.

FDR had it, hyperthymia, survivors of trauma and hardship sometimes get it. We see it most often in the descendants of people who once had bi-polar disorder. Teddy Roosevelt, a fifth cousin to FDR, apparently suffered from bi-polar disorder, and Isaac Roosevelt, FDR's grandfather, a trained physician, never practiced. People thought him odd. Take note of the importance of a genogram, that family tree, early in treatment.

Here's how Dr. Ghaemi, in his wonderful little book, describes FDR : (italics mine)
HE WAS HIGHLY SOCIABLE. On his Harvard alumni questionnaire, when asked his aversions, he replied, "None." He spent about a quarter of the working day on the telephone without means of an intermediary. He know how to get people to do what he needed, even if they did not agree with him about why. Once, when asked why he asked political opponents to serve in his administration, he commented, "You know, a man will do a lot of right things for the wrong reasons."

His longtime associate and secretary of labor Frances Perkins (also a social worker, read her biography) called him "incurably sociable," even needing to read books aloud to others rather than by himself. His close aide Robert Jackson, who served him as attorney general and later as a Supreme Court justice, viewed FDR's sociability as his strongest asset: "It was here that Roosevelt was irresistible and inimitable. He liked people, almost any people. He liked their company, liked to pick their minds and see what they were thinking, liked to know the details of their lives and problems."
I shudder. I know him.  A genetic heartbeat away from real mania, more functional, and more loveable than any American leader ever, some say.

Therapists are much more likely to see bi-polar disorder and uni-polar depression, than a hyperthymic personality. Before I had ever heard the word, I labeled the condition (hyperthymia) as uni-polar, the good kind, the opposite of true unipolar depressive disorder, the only unipolar disorder in the DSM IV-TR.

We often catch uni-polar depression or bi-polar disorder when people can't function, aren't meeting their potential.  Kids are coerced to coming to therapy for not getting homework done, or not getting it in on time, breaking curfew.  They will say, (italics mine):
I can’t do it, there is no doing it, not this; my brain isn’t there.  I can’t focus, can’t see why I even should focus on school.  I do other things (more compelling things).  Doing my assignments feels absurd, a waste of time.  Did I tell you about the new guy I met downtown?  Let me play something for you on my harmonica. Can I just show you something on YouTube? Get me out of school, would you please?  These people, my teachers, are making me crazy. Could you, doctor, please?
Or they are too depressed to say anything.

Therapy, a quest for sanity, is a parental request. The bi-polar child, like an adult with the same disorder, is either vegetative or unstoppable, more than occasionally unreasonable, and often brilliant. Mad, brilliant, neither one without the other, indistinguishable, certainly, to themselves.

We distinguish it quite well, of course. Most of us don't trust people when they're too high. And they're not all geniuses. John F. Kennedy, in Ghaemi's good leader group, didn't shine academically, and most don't believe him to have been a genius.  But he was certainly manic, as were many of his relatives, and he had bouts of depression and suicidality. Still, he empathized with the down-trodden, and used his position for positive societal change.

We tend to find more often, however, is that the afflicted bi-polar disorder have less peripheral vision, not more, only see what their brains command them to see.  Significant others, family and friends, are lost. No empathy, not in the episode.Greatness will be during remission, perhaps, hypomania.

Indeed the manic adults we know aren't generally Presidents, they are not the political leaders.  They are your every day Joes, Janes, and when they have authority, will think so fast that others find them impossible, and their demands time-intensive and unreasonable.  The boss doesn't come to therapy.  His employees do.

Less manic at the top of the company (or family), the work is more likely to get done, and get done well. Similarly, rock stars who finally quit drugs will admit their work is better, straight. Like imbibing too much too often, sliding too far up or down, going manic or catatonic, creativity suffers.

Yet a select few, according to Dr. Ghaemi, still achieve greatness, in large part because of their illness.  The irresoluteness of mania, the empathy following depression, big things get done.

They are the minority, but we see them.  Nassir Ghaemi's detractors will say that for most, a bi-polar disorder diagnosis is tantamount to selfishness and inaccessibility.  The empathetic moments are too few and far between.  And we really can't tell a manic brain, not even the brain of a hyperthymic individual, necessarily, to go someplace it doesn’t want to go.

Ordinary people do what is expected of them.  We meet expectations, take one for the team.  We go to work because we know that if we don’t, we won’t get paid, and the family needs the money. We put one foot in front of the other, even when we don't feel like it, and go.  We can make ourselves go.

That's because we're ordinary. You can’t make an extraordinary brain do something ordinary.

The ordinary don't make good leaders, however, according to Dr. Ghaemi's thesis.  The normal among us, homoclites, aspire to do well, be good, and be liked. We carry on quietly, seek simple comfort, do what is expected.

A president like George Bush, normal in every way, even in his alcoholism (described as progressive until dysfunctional, when he chose to quit) is destined to fail his people in a crisis.  President Bush responded to 9-11 like normal people respond to an attack. Attacked, President Bush attacked back. And he didn’t have the guts, he didn’t have feeling enough for the dead and the victims in that far away land, to get out.

People with mental illness, on the other hand, are more empathetic (when not in the throes of an episode). They can’t deny their feelings, the breadth and depth of sadness they feel for the hard of luck, the down and out, the poor. Gandhi, Martin Luther King, Abraham Lincoln, all suffered from severe affective disorders and subsequently, empathized. Their empathy moved them to greatness, to do great things for humanity.

Ghaemi's thesis: There is an association between having suffered mental illness and choosing to do the right thing, even becoming a great leader in crisis.


That’s what I tell those young people, having read his book, the ones who can’t do their homework, the ones who can’t make their brains go where everyone else's brains, those ordinary brains, have no problem going. Think, greatness.  First rate.

therapydoc

Post Script:

(1) A First Rate Madness is a first rate book. I don’t even want to lend mine out. Nassir Ghaemi is wonderful writer, and I’m sure a very empathetic psychiatrist. He reviews many leaders, even Hitler, and defines Hitler’s followers as homoclites, just following orders.

Reflecting on that, post 9-11, I suppose this explains the popularity of terrorism. Suicide bombers, terrorists, are normal; they are followers. Having swallowed a leader’s ideology, they do what normal people do. They fight for what they believe is the truth.



(2) Nassir writes more than your average psychologist, but not more than your average hyperthymic blogger. Check out his blogs, Mood Swings and Free Associations.

(3) To read other bloggers who reviewed A First Rate Madness, check out:
Justice Jennifer
A Library of My Own
Chunky Monkey
What Would the Founders Think?
Lit Endeavors
A Bookish Affair
The Left Coaster
Deep Muck Big Rake
Scheduled soon:
The Abraham Lincoln Blog
They Gave Us a Republic

Sunday, September 11, 2011

Reversing the Decay of London Undone

Oh, it's a maximalist post, I guess, not terribly accessible, and not for the feint of heart.  Reflects that 911 mood.

Everyone needs therapy is a self-serving bias, you know, for a family therapist. But I look around and wonder. Would it really help society, if everyone talked to a professional, at least once, say, preferably, before the age of nineteen?  Think of it as immunization.

Late adolescence might be the best time to do it.  Get some perspective, look back at life, think about who you want to be, where you've been, where you want to go. When children reach late adolescence, families grapple with their launching.  Some make differentiation, individuation, leaving home, difficult.  All kinds of psychiatric symptoms pop up then.  Read Jay Haley's classic family therapy tome, Leaving Home.

Nineteen is about the age I got some therapy (group therapy-- strongly recommended for the unsure) and it was powerful, all about the tragic loss of a brother, how that affected our family system. He was twenty, I was eighteen; it was an accidental death. We think.

Why mention it? The London riots, of course.  Young, reckless people in the streets, doing what feels good. I can’t help but wonder what my brother would have made of it. We would have shared memories of times gone by, were he alive today.

We wore black armbands in our day to protest a war. And thousands came to Chicago to change the world, rearrange the world (Crosby, Stills, and Nash), and to congregate in Grant Park as delegates congregated at the Hilton for the 1968 Democratic National Convention. Mayor Richard Daley, grasping at control, made his famous Shoot to Kill order to Chicago's Finest, the police.

The National Guard readied to fight off the long-hairs in the park.


A different time, but a riot nevertheless.

Those times marked the beginning, according to Britain's Chief Rabbi, Jonathan Sacks, of the end of morality.



But Reversing the Decay of London Undone isn't about the detritus of the recent riots.

Rabbi Sacks tends to be a deep thinker.

In a pile of papers on my desk, I still have his December 11, 2010 thoughts on the weekly Torah portion, Vayigash (that favorite about that family reunion in Egypt, the one with Joseph and his errant brothers).  I printed it out and saved it to blog about one day.

Writes the rabbi:

What do porcupines do in winter? asked Schopenhauer. If they come too close to one another, they injure each other. If they stay too far apart, they freeze. Life, for porcupines is a delicate balance between closeness and distance. It is hard to get it right and dangerous to get it wrong. And so it is for us.

That kind of stuff we talk about here! But the piece for the Wall Street Journal, the one about decay in London, is less philosophical, less about intimacy, more of what we would expect from a clergyman admonishing return to the fold. Not that it isn't relevant, but it isn't especially new. The disappearance of morality didn't happen overnight, point well taken, but clergy of all stripes have been preaching about returning to that hometown religion, for years.

Riots give us pause, cause to wonder, What's going on? The Chief Rabbi's answer is perhaps the best answer, no morals. But his solution, return to the fold, untenable.  Idealistic advice, works for some, but is unlikely to be heard by the masses, divine intervention excepted.  Chaval.  (Chaval rhymes with shah-doll, means a pity, a shame, Hebrew, hard "ch".)

Last night I downloaded a movie, Cedar Rapids. My brother-in-law thought we might find it enjoyable because it is about a sweet guy, an innocent man, an orphan who lost his parents as a child, and yet, he becomes a successful insurance agent, a positive force in the universe, cheerful and good. Our hero is chosen to attend a convention in the big city.  He has never been on an airplane before, never been to the airport. In the big town of Cedar Rapids, at the convention, immorality abounds, and he's all for it. He's in, as we say today. None of us in the room are surprised.

People party, especially on vacation, in Vegas, in cities all over the world, at conventions. The moral compass,  passed from generation to generation, points every which way, away from home. The rabbi's lament, that the compass is off kilter entirely due to the disconnect, especially a disconnect from religious community, is a logical corollary.  Call it  morality-dilute. Religion keeps us straight.  No religion, anarchy. Riots.

Wrong is right, and right is wrong, because nobody goes to shul* anymore. Religion is anachronistic, rules arbitrary, the enlightened too smart for dogma. Everyone has left the shtetel,** the parish, the church.  It is the disconnectedness, accordingly, responsible for social chaos. Return to religion, to moral identity, to save the world.

For a moment, Rabbi, with all respect, let me speak for the disconnected. Let me speak for the children who are losing virginity at fifteen years old, some say well over the majority of American youth, and a general populace that ingests a steady diet of seductive media. For at least one generation, unbounded sexuality is normal.  Sex is normal; it is like food, air.  And violence, too, is unconsciously accepted.  We have only to see what is on television any given moment, or peruse the popular video games.

But let's talk about sex, because the death of morality started with that sexual revolution, theoretically. Woodstock, Haight-Ashbury, some might wrongfully say, with feminism.  (See how difficult this is?).

A woman is sitting across from me. She is a beautiful specimen, one of creation's finest. When she comes to see me I think, Why is she seeing me? But this is my reaction to most everyone who sees me lately. They are all beautiful. They are all young. They are all confused.

I learn that she is in therapy because she is lonely. Someone has left her, someone she loved. Switch genders here as needed, he has left her for someone else. My patient blames herself, has no idea what went wrong, truly no clue. It all seemed so good. He was loving, attentive until the break-up, which was not conflictual. She thought he was the one, that the relationship would go the distance. But it didn't.

I have seen dozens of her and each time am taken aback at the naivete. It was so good, how could it be over?
People get bored, dear. Even when things are good, perhaps especially then.
She grieves the death of a relationship, grieves having been fooled. She uncovers lies, tells them over to me.  It wasn't as she thought, was never an exclusive, committed relationship.

She cannot use the word monogamous, for this word isn't in her lexicon or that of her peers, doesn't apply.  Monogamy implies marriage, and marriage only follows successful cohabitation in our brave new world.  Quite a feat, making it last, without a contract.  But some do, reinforcing this crap shoot, cohabitation, the gold standard of relationships. As good as it gets.

No one wants to be lonely.

I'll put it in a way that the clergymen might or might not, leave out the sin, the fire and brimstone bit. Maybe the clergy do discuss this dynamic, who lives with who and when, but in my particular shtetel they don't. So allow me.

From a psycho-therapeutic vantage, it is an emotional risk living together-- with marriage or without.  Even without cohabitation, sexual intimacy is a risk, for it is exposure of a very personal kind.  Yet it is expected, even before the other types of intimacy have been established, before the other relationship muscles get any exercise at all.

He'll leave (without sex) the women all tell me. The men complain, She demands it. (When a man is reluctant, he must be gay.)  Thus the market for Viagra in this sexual economy will never die. This is a stock worth your money, if you can stomach the profit. It feels wrong to me. We've talked about loving sex, how that works, sans Viagra. It's all about something called communication.  Listening.

What is the therapeutic response to a patient suffering relationship loss, seriously?  Go back to church? Go back to the synagogue, the mosque? Where is this place? It isn't around the corner.  My patients know no one who attends. They avoid needed 12-Step meetings for their many addictions because it is a drag, all that talk about a Higher Power. The Higher Power is we, apparently.

When I direct patients to socialize for connectedness (because we all need this, badly), I keep it vague.  Some seek out parochial resources, even online dating, but others can't connect to anything resembling control, and they see religion as just that, something that cramps their style, external control.

All we can do, when we do therapy, is work through the pain, reconstruct identity.  We coach new behaviors, empathize, and reassemble lives.  They pick up the pieces and try to do it differently next time. 

In good  therapy, when we talk about the breach of trust, deception, the psycho-educational piece is early detection.  That is only possible with emotional intimacy, words, discussion fairly early into the relationship about childhood, something people tiptoe around.  Deception detection is about discovery.  How did this person discover truth as a better strategy to stress, over lying?  Most of us make this discovery somewhere in our childhood.  It can be an  epiphany.  How did it work, lying, acting out?  Everyone has stolen something, if only trust.  How did it change her?  Discuss how you, how he, she, got away with things in life.  Most of us brag about things like this and it tells us a great deal about character.

The more social among us listen to the woes of our friends.  We suffer along with them when they are hurting.  We empathize and we bask in the glow when it is returned.  We talk about how sexual intimacy enhances human connectedness, the loss, therefore, commensurate.  We hold on to one another, and no, we don't have to be therapists or a pastoral counselors to be a part of social healing.

Empathy is, and maybe should be, the new religion. If the clergy teach anything from the pulpit, they should teach empathy. Perhaps it will trickle down, somehow, to the streets.

And those kids rioting in London?  Some really will go to jail, some will become lifelong criminals, others are just finding themselves and will turn around.  We'll see if they feel shame, if they have remorse, when the dust settles. 

The good news is that in jail, where freedom is lost, some look outside themselves.
They look up. Having lost all autonomy and control, they search for meaning.  Sometimes, they find God.

And others, therapy.

therapydoc

*shul--rhymes with pull, means synagogue
**shtetel-- rhymes with get-ill.  Every ethnic group, every religion, still has one of these core community within big cities